ANNEXURE B (For the candidate)
Location of Apollo Hospital................................................................................................................
Clinical fellowship applied for.............................................................................................................
Speciality........................................................................................................................................... Photograph
Duration of Clinical fellowship……………………………………………………………………………………………………..
Name of Consultant/ Guide………………………………………………………………………………………………………
PERSONAL PARTICULARS
1. (a) Name (in capital letters) (as appearing in MBBS certificate)
(b) Father's / Husband's Name & Occupation
(c) Reg. No. of State/ Delhi Medical Council Dated
(d) Reg. No. of MCI Dated
3. Date of Birth (as per Matriculation Certificate)
D D M M Y Y Y Y
4. Address for correspondence.
Name...............................................................................................................................................................
Address………………………………………………………………………………………………………
………………………………………………………………………………………………………………
Pin------
Telephone No.(Residence)…………………………… Mobile No ………………………………………
E-Mail………………………………………………………………………………………………...
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5. Permanent Address:-
Name............................................................................................................................................................
Address…………………………………………………………………………………………………….
……………………………………………………………………………………………………………..
Pin------
Telephone No.(Residence)…………………………… Mobile No ………………………………………
E-Mail………………………………………………………………………………………………..
6. Educational Qualifications:-
Examination Passed Name of university /Board / Year of Passing %/ Marks
State
1. M.B.B.S.
2. MD/MS/DNB
3.Others
b). Papers published (i) ……………………………………………………….
(ii)……………………………………………………….
(iii)……………………………………………………….
(iv)……………………………………………………….
7. Experience/Details of employment (as per format)
Speciality/ Discipline/ Name of the Hospital Designation Period Total
Department From To Period
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8. I hereby declare that
a. Particulars given in this application form are true and accurate to the best of my knowledge and belief.
b. I hereby undertake to abide with and strictly follow the code of conduct and discipline of the hospital.
c. I agree to undergo the training in the course applied for, and, undertake to abide with the Rules & Regulations of
Apollo Hospitals.
d. Any change in my personal particulars given above will be notified immediately on occurrence to the Academic
Advisor office of the Hospital.
e. Joining of the candidate is subject to his/her medical fitness. The medical examination of the candidate shall be done
by the Medical Board of this hospital/institute. Candidate found fit in the medical examination shall only be allowed
to join the clinical fellowship.
_________________________________ _____________________________
Candidate Name in block letters Signature of the Candidate
Date: / / (Use only Blue /Black Ballpoint Pen)
CHECK-LIST OF DOCUMENTS REQUIRED TO BE ATTACHED WITH THIS FORM
Please enclose attested copies by a Gazetted Officer/Self Attested of the following certificates with your application in the
order given below:
a). M.B.B.S. Degree & all Mark sheet
b). MD/MS/DNB/ MCh( as applicable)
c). Self-attested copies of Matriculation / Higher Secondary certificate/ Driving Licence/ Passport showing date of
birth.
d). Registration Certificate of State Medical Council.
e). Two passport size photographs
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